Operational Medicine Medical Education and Training

Performing a Pap Smear

The Cervix

The cervix is located at the top of the vagina. It is the opening to the uterus and is composed of dense connective tissue. It has very little smooth muscle in it, compared to the rest of the uterus, which is almost entirely smooth muscle.

The cervix is visualized by placing a speculum in the vagina. At the top of the vagina is a smooth, pink, firm structure with an opening (the os) in the center, which leads to the uterus.


 

 

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The Pap Smear

In the 1940's, Dr. Papanicolaou developed a technique for sampling the cells of the cervix (Pap smear) to screen patients for cancer of the cervix. This technique has proven to be very effective at not only detecting cancer, but the pre-cancerous, reversible changes that lead to cancer.

While not originally designed to detect anything other than cancer, the Pap smear has proven useful in identifying other, unsuspected problems.

So useful has the Pap smear become, it is considered an essential part of women's health care. It is typically performed annually in sexually-active women of childbearing age, although there are some important exceptions.

Because the Pap smear is a screening test, it can have both false positive and false negative results. For this reason, it is important to have the test performed regularly (annually in the military services). It is not likely that the Pap smear will miss an important lesion time after time.

Pap smears are best performed in a stable, garrison situation because of the time it takes to send out the smear, have it read, get the result back, and perform any follow-up care that is needed. The actual obtaining of a Pap smear can be done almost anywhere (at sea, in the air, in the field), but getting the results back and further treatment performed in these operational settings can be difficult or impossible.

Dysplasia

Dysplasia means that the skin of the cervix is growing faster than it should.

Cervical skin cells are produced at the bottom of the skin (basal layer). As they reproduce, the daughter cells are pushed up towards the surface of the skin. As they rise through the skin layer, they mature, becoming flat and pancake-like (as opposed to round and plump). Their nuclei initially become larger and darker. If these daughter cells reach the surface of the skin before they are fully mature, a Pap smear will reveal some immature cells and "dysplasia" is said to exist. 

There are degrees of dysplasia: mild, moderate, and severe. None of this is cancer, but the next step beyond severe dysplasia is invasive cancer of the cervix. For this reason, any degree of dysplasia is of some concern, but the more advanced the dysplasia, the greater the concern.

Mild Dysplasia

Mild dysplasia means the skin cells of the cervix are reproducing slightly more quickly than normal. The cells are slightly more plump than they should be and have larger, darker nuclei. This is not cancer, but does have some pre-malignant potential in some women. Other phrases that describe mild dysplasia include:

  • LGSIL (Low-grade Squamous Intraepithelial Lesion)

  • CIN I (Cervical Intraepithelial Neoplasia, Grade 1)

Many factors contribute the development of mild dysplasia, but infection with HPV, (Human Papilloma Virus) is probably the most important. Smoking tobacco products and an impaired immune system also may contribute to this.

Mild dysplasia can come and go, being present on a woman's cervix (and Pap smear) at one time and not another.

Of all women who develop mild dysplasia of the cervix, about 10% will, if untreated, slowly progress through the various degrees of dysplasia and ultimately develop invasive cancer of the cervix. The rest will either remain unchanged or regress back to normal.

Because so many cases of mild dysplasia regress, It is common for women who develop a single Pap smear showing mild dysplasia to be watched over time with the Pap smear being repeated in 6 months. If the dysplasia persists or worsens, further evaluation is undertaken. If the Pap returns to normal, the woman's cervix is followed, sometimes with more frequent Pap smears.

Other physicians feel that the cervix should be evaluated with colposcopy with even a single dysplastic Pap smear. Their reasoning is that while many of the Pap smears revert to normal in 6 months, the abnormality will often re-appear at a later, less convenient time. They also reason that many women will feel anxiety over simply observing the abnormality over time and not investigating it right away. Operational circumstances may well dictate the approach that needs to be followed.

For women who have previously been evaluated with colposcopy and found to have dysplasia, the appearance of mild dysplasia on a subsequent Pap smear is not particularly alarming. Whether to re-colposcope them and the timing of such a re-evaluation must be individualized, based on the operational circumstances, the patient's history, risk factors, the degree of abnormality in the past and intervening Pap smear results. It is best to consult with an experienced colposcopist or gynecologist before making a final decision.

Treatment of mild dysplasia may be cryosurgery (freezing the part of the cervix containing the dysplastic cells and destroying those cells). Other approaches include vaporizing the dysplastic cells with a laser, or shaving them off with an electrified wire (LEEP). Sometimes, the mild dysplasia is not treated at all, but the patient is closely watched instead. If the dysplasia advances to a more severe stage, treatment can be undertaken at that later time. But for women in low-risk situations whose cervical lesion does not advance, surgery can sometimes be avoided.

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